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Home , Aseptic meningitis

Published online: 2019-09-26

Original Article

Estimation of cortisol level in tuberculous Rohan R. Mahale, Anish Mehta, Sudhir Uchil1 Departments of and 1Medicine, M. S. Ramaiah Medical College and Hospital, Bengaluru, Karnataka, India

ABSTRACT Background: (CNS) involvement in tuberculosis is around 5–10%. Of the various manifestations of CNS tuberculosis, meningitis is the most common (70–80%). Delay in diagnosis and treatment results in significant morbidity and mortality. Objective: To study the cerebrospinal fluid (CSF) cortisol levels in tubercular meningitis and compare the levels with controls. Methods: Cross‑sectional, prospective, observational, hospital‑based study done in 20 patients of tubercular meningitis, 20 patients of aseptic meningitis (AM) and 25 control subjects without any preexisting neurological disorders who have undergone for spinal anesthesia. Results: Cortisol was detected in all 40 CSF samples of patients (100%). Mean CSF cortisol level was 8.82, 3.47 and 1.05 in tubercular meningitis, AM and controls, respectively. Mean CSF cortisol level in tubercular meningitis was significantly higher as compared to AM and controls (P < 0.0001). Conclusion: Cortisol level estimation in CSF is one of the rapid, relatively inexpensive diagnostic markers in early identification of tubercular meningitis along with CSF findings of elevated proteins, hypoglycorrhachia and lymphocytic pleocytosis. This aids in earlier institution of appropriate treatment and thereby decreasing morbidity and mortality. This is the first study on the estimation of CSF cortisol level in . Key words: Cerebrospinal fluid, cortisol, marker, meningitis, tuberculous

Introduction diagnosis of TBM. Contemplated confirmatory diagnostic tests based on the detection of the mycobacterium for Tuberculosis remains a major public health problem TBM includes CSF smear for acid fast bacilli (AFB) and in developing countries,[1] mostly seen in age group CSF culture for AFB. Demonstration of AFB in CSF is of 15–59 years. However, increasing incidence of the single most important procedure for a definitive human immune deficiency virus, there is a potential diagnosis. CSF smear for AFB is positive in 5–37% for re‑emergence of tuberculosis as a significant cases and the CSF culture for AFB is positive in 40% public health problem in the developed countries as cases.[5,6] It is estimated that for demonstration of AFB on well.[2] Of the various manifestations of central nervous smear, bacterial load of 10,000 AFB/ml is required and system tuberculosis, meningitis is the most common for culture to be positive; there shall be 100 AFB/ml of (70–80%) followed by tuberculoma.[3] Tuberculous CSF. It is tedious, and time‑consuming to grow tubercle meningitis (TBM) is associated with significant bacilli on culture requiring 3–8 weeks. Polymerase chain neurological sequelae, high morbidity and mortality.[4] reaction (PCR) test is a highly sensitive and specific test, Clinical suspicion supported by careful cerebrospinal but is very costly and not widely available.[7,8] Hence, fluid (CSF) analysis is the only method even today for the newer rapid, relatively inexpensive diagnostic markers in diagnosis of TBM. CSF analysis plays a pivotal role in the CSF are required for the diagnosis of TBM. The objective of this study was to study the CSF cortisol levels in TBM Access this article online in comparison with aseptic meningitis and controls. Quick Response Code: Website: www.ruralneuropractice.com Methods

DOI: Patients and setting 10.4103/0976-3147.165421 A total of 25 patients clinically suspected of tubercular meningitis and 20 patients clinically suspected of

Address for correspondence: Dr. Rohan R. Mahale, Department of Neurology, M. S. Ramaiah Medical College and Hospital, Bengaluru ‑ 560 054, Karnataka, India. E‑mail: [email protected]

Journal of Neurosciences in Rural Practice | October ‑ December 2015 | Vol 6 | Issue 4 541 Mahale, et al.: CSF cortisol in tuberculous meningitis aseptic meningitis, who were admitted in M.S Ramaiah Analysis of cerebrospinal fluid‑cortisol level hospitals, Bangalore, India were recruited for the study. A fresh sample of CSF obtained by the lumbar puncture The study period was from July 2009 to July 2011 and was was collected in heparinized vial and analyzed for approved by the institute ethics committee. All subjects the cortisol estimation by direct chemiluminescence or their caregivers gave written informed consent after assay using ADVIA Centaur CP system. The ADVIA full explanation and detailed description of study Centaur CP cortisol assay is a competitive immunoassay method. The inclusion criteria included age 18 years or using direct chemiluminescent technology. Cortisol greater, patients presenting with fever, headache and in the patient sample competes with acridinium ester meningeal irritation and lumbar puncture performed labeled the cortisol in the Lite Reagent for binding upon admission to the hospital. The Medical Research to polyclonal rabbit anticortisol antibody in the solid Council (MRC) staging of TBM:[9] Stage 1: Prodromal phase. The polyclonal rabbit anticortisol antibody is phase with no definite neurological symptoms or signs; bound to monoclonal mouse antirabbit antibody, which Stage 2: Signs of meningeal irritation with slight or no is covalently coupled to paramagnetic particles in the clouding of consciousness and minor (cranial) nerve solid phase. palsies or neurological deficits; Stage 3: Severe clouding of consciousness, stupor, coma, convulsions, gross The following CSF cytochemical parameters for TBM paresis or involuntary movements were carried out were used: Protein: 1–5 g/L, cell counts: 10–500 cells/µL; in all included patients. Patients with a predisposition lymphocytic predominance; glucose: 20–40 mg/dl.[10] for bacterial meningitis such as bacterial sinusitis, otitis media, CSF rhinorrhea and patients with history Statistical analysis of head injury and nasal or ear bleeding, partially The data were analyzed using SPSS 17 (IBM inc.). The treated cases (which included and steroids) continuous variables were expressed as mean ± standard were excluded from the study. Five patients met the deviation and categorical variables as frequency and exclusion criteria and were excluded from the study. percentage. The normality of the distribution was 25 patients (15 males and ten females) without any assessed by the skewness of the values. For the analysis preexisting neurological disorders who underwent of continuous variables, nonparametric testing (Mann– Whitney test and Wilcoxon’s test) was employed. spinal anesthesia were included as controls. All patients and controls were examined by one of the authors (A.M.). P < 0.05 was taken as statistically significant. The study was prospective, cross‑sectional, observational and hospital‑based. Results

Investigations Demographic and clinical data All the patients underwent thorough clinical examination. A total of 20 patients clinically suspected of TBM were The following information was documented in the recruited during the study period. Mean age of patients predesigned proforma: Characteristics of fever, headache, with meningitis was 45.6 ± 17.4 years (range: 21–68). level of consciousness, details about convulsions, There was slightly higher proportion of males (n = 12) focal neurological deficits, history of surgeries and as compared to females (n = 08) with M: F ratio of 1.5:1. co‑morbidities such as diabetes, pulmonary or The most common clinical symptom was fever (20/20), extra‑pulmonary tuberculosis. Following investigations headache (16/20), altered level of consciousness (16/20) were carried out in all the patients that include complete and convulsions (8/20). The most common clinical blood count, renal, hepatic function tests, serum signs were neck stiffness (20/20), drowsiness (17/20), electrolytes, random blood sugar: At the time of lumbar irritability (15/20), stupor (5/24), cranial nerve puncture, chest X‑ray, abdominal ultrasonography, deficits (15/30) and hemiparesis (8/20). The duration of blood culture, CSF study: Cytochemical analysis‑cell symptoms was < 1 week in 3 (15%), 1–3 weeks in 12 (60%), count, cell type, protein, sugar, cortisol estimation by >3 weeks in 5 (25%) patients. chemiluminescent method, gram stain and ZN stain, culture for mycobacteria and bacteria, TB PCR, Herpes Clinical course of patients with tubercular meningitis Simplex virus PCR, India ink preparation, cryptococcal A total of 20 patients presented with tubercular antigen and malignant cell cytology. Neuroimaging in meningitis. CSF TB‑PCR was positive in 6 patients. the form of the computed tomography head or magnetic CSF culture was positive for mycobacterial growth in resonance imaging was done in all patients to rule four patients. Six patients had pulmonary tuberculosis, out structural brain lesion before lumbar puncture. CSF and eight patients had tubercular lymphadenitis. Three examination was done as soon as a patient got admitted patients were in stage 1 (3/20), twelve patients in stage before the first dose of antibiotics or steroids were given. 2 (12/20) and five patients in stage 3 (5/20) according to

542 Journal of Neurosciences in Rural Practice | October ‑ December 2015 | Vol 6 | Issue 4 Mahale, et al.: CSF cortisol in tuberculous meningitis

MRC staging of TBM. Favorable outcomes of tubercular Table 1: Cytological and clinical chemistry parameters meningitis were observed in 15 patients (75%) with in blood and CSF in patients with tubercular meningitis three patients having focal neurological deficits and aseptic meningitis due to tubercular arteritis (15%), two patients had Parameters Tubercular Aseptic (viral) obstructive hydrocephalous requiring CSF diversion meningitis (n=20) meningitis (n=20) procedures (10%). Blood WBC count (cells/mm3) 7350 (4080-10,200) 6950 (3700-8920) Clinical course of CSF 3 A total of 20 patients had CSF features suggestive of WBC count (cells/mm ) 494 (78-3000) 146 (110-200) Cell type (predominant) Lymphocytes Lymphocytes viral meningitis. CSF HSV PCR was positive in eight Protein (mg/dl) 195.2 (112-449) 47.6 (37-74) patients; varicella‑zoster virus PCR was positive in Glucose (mg/dl) 36.4 (16-56) 48.9 (43-55) five patients and unknown etiology in seven patients. CSF/serum glucose ratio 0.31 (0.13-0.41) 0.49 (0.38-0.54) Favorable outcomes of viral meningitis were observed Data are presented as mean (range). CSF: Cerebrospinal fluid, WBC: White blood cell in all 16 patients (80%). Table 2: Comparison of CSF cortisol levels between Cytology and chemistry of cerebrospinal fluid tubercular and controls Serum and CSF cytological and clinical chemistry Groups (n) CSF cortisol levels (µg/dl) P parameters in the tubercular meningitis and aseptic Tubercular meningitis (n=20) 8.82±0.67 (4.7-14.8) <0.0001 meningitis are summarized in Table 1. Aseptic meningitis (n=20) 3.47±0.96 (2.5-5.6) Controls (n=25) 1.05±0.36 (0.2-1.7) Cortisol level in cerebrospinal fluid Data are presented as mean±SD (range). CSF: Cerebrospinal fluid, Cerebrospinal fluid cortisol levels in tubercular SD: Standard deviation meningitis, aseptic meningitis and controls are these levels decreased after treatment, high levels were summarized in Table 2. The mean CSF cortisol level maintained at the end of 6 months of treatment.[13‑15] in tubercular meningitis group was significantly higher as compared to aseptic meningitis and control Antinflammatory cytokines are also highly produced

groups (P < 0.0001). wherein; they protect tissue damage by excessive inflammation and induce nervous tissue regeneration.[11] Discussion Murine model of TBM‑induced by the intratracheal showed high expression of antiinflammatory The present study was aimed at determining the CSF cytokines in the brain, such as IL‑10, IL‑4, and cortisol levels in TBM. Twenty patients with TBM and transforming growth factor‑β, which apparently protect aseptic meningitis were studied, and CSF cortisol levels tissue destruction from excessive inflammation.[16,17] were assessed in them before institution of treatment. Many studies have indicated an important role for CSF cortisol levels in both groups were compared with cortisol as an anti‑inflammatory response.[18] the control group. CSF cortisol levels were significantly elevated in patients with TBM as compared with Cortisol is a small lipid‑soluble molecule produced in concentrations in aseptic meningitis group and healthy adrenal glands after stress stimulation such as infection, control individuals. This is the first study determining trauma or major surgery. It circulates in the blood mainly the level of cortisol in CSF in patients with TBM. in the protein‑bound forms, the majority being attached to corticosteroid binding globulin. The half‑life of cortisol Mycobacterial infection induces the production of in the circulation is about 80 min, with approximately proinflammatory cytokines that are important for bacilli 1% excreted unchanged in the urine. Increase in cortisol killing, but they can also produce immunopathology.[11] secretion takes place very quickly, within minutes in At the early stage of mycobacterial infection of brain, acute stress conditions, and can stay at high levels for proinflammatory cytokines such as tumor necrosis long periods, sometimes days, months, and even years.[19] factor‑α (TNF‑α), interleukin (IL‑1 and IL‑6) are released It easily crosses the BBB. Schwarz and Pohl demonstrated by migrated activated macrophages, microglial cells, that cortisol transport through BBB is not increased astrocytes, and endothelial cells. These cytokines by its leakage and is rather dependent on serum are responsible for the damage to the blood brain concentrations.[20] It has been suggested that intrathecal barrier (BBB).[12] High concentrations of interferon‑γ, and concentrations of steroid hormones are maintained by TNF‑α have been detected in the CSF of TBM patients in their active transport out of the brain.[21] Disturbance of correlation with the severity of the disease, and although this mechanism by inflammation, with reduced ability

Journal of Neurosciences in Rural Practice | October ‑ December 2015 | Vol 6 | Issue 4 543 Mahale, et al.: CSF cortisol in tuberculous meningitis of brain cells to metabolize sterol molecules, may lead to 3. Ray H, Riggs HE, Rupp C. Clinicopathologic study of tuberculous the persistent increase in CSF cortisol.[22] During critical meningitis in adults. Am Rev Tuberc 1956;74:830‑4. 4. Anderson NE, Somaratne J, Mason DF, Holland D, Thomas MG. illness, cortisol‑binding globulin and albumin blood Neurological and systemic complications of tuberculous meningitis and levels decrease by about 50%, leading to an increase in its treatment at Auckland City Hospital, New Zealand. J Clin Neurosci biological active free cortisol. 2010;17:1114‑8. 5. Bishburg E, Sunderam G, Reichman LB, Kapila R. Central nervous system tuberculosis with the acquired immunodeficiency syndrome and Holub et al., have shown elevated CSF cortisol levels its related complex. Ann Intern Med 1986;105:210‑3. in patients with bacterial meningitis, and it correlated 6. Ahuja GK, Mohan KK, Prasad K, Behari M. Diagnostic criteria with disease severity.[22] Similar elevation in CSF for tuberculous meningitis and their validation. Tuber Lung Dis 1994;75:149‑52. cortisol levels were seen in patients with aseptic 7. Bothamley GH, Rudd R, Festenstein F, Ivanyi J. Clinical value of the (AM) suggesting an important role measurement of Mycobacterium tuberculosis specific antibody in of cortisol in AM.[23] There are no studies on CSF cortisol pulmonary tuberculosis. Thorax 1992;47:270‑5. 8. Beavis KG, Lichty MB, Jungkind DL, Giger O. Evaluation of Amplicor levels in patients with TBM. PCR for direct detection of Mycobacterium tuberculosis from sputum specimens. J Clin Microbiol 1995;33:2582‑6. The strength of the study is the estimation of CSF cortisol 9. Kennedy DH, Fallon RJ. Tuberculous meningitis. JAMA 1979;241:264‑8. 10. Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. level in patients with TBM immediately before starting Harrison’s Principles of Internal Medicine. 18th ed. United States of empirical antibiotics or steroids. However, this study America: The McGraw‑Hill Companies, Inc.; 2011. is not devoid of limitations. Smaller cohort of patients 11. Jaffe IP. Tuberculous meningitis in childhood. Lancet 1982;1:738. in TBM group in this study is one of the limitations. 12. de Vries HE, Kuiper J, de Boer AG, Van Berkel TJ, Breimer DD. The blood‑brain barrier in neuroinflammatory diseases. Pharmacol Rev Correlation of CSF cortisol with disease severity and 1997;49:143‑55. long‑term outcome scores were not carried out. For 13. Mastroianni CM, Paoletti F, Lichtner M, D’Agostino C, Vullo V, Delia S. rapid etiological diagnosis in meningitis, various CSF Cerebrospinal fluid cytokines in patients with tuberculous meningitis. Clin Immunol Immunopathol 1997;84:171‑6. parameters along with a new parameter in the form of 14. Nagesh Babu G, Kumar A, Kalita J, Misra UK. Proinflammatory cytokine CSF cortisol assay must be combined. The results of the levels in the serum and cerebrospinal fluid of tuberculous meningitis present study should be a basis for larger, prospective patients. Neurosci Lett 2008 2;436:48‑51. 15. Misra UK, Kalita J, Srivastava R, Nair PP, Mishra MK, Basu A. A study clinical study regarding utility of CSF cortisol as a of cytokines in tuberculous meningitis: Clinical and MRI correlation. diagnostic biomarker in TBM. Neurosci Lett 2010;483:6‑10.

16. Hernández PR, Aguilar D, Cohen I, Guerrero M, Ribon W, Acosta P, et al. Specific bacterial genotype of Mycobacterium tuberculosis Conclusion cause extensive dissemination and brain infection in an experimental model. Tuberculosis (Edinb) 2010;90:268‑77. 17. Hendrix S, Nitsch R. The role of T helper cells in neuroprotection and Cerebrospinal fluid cortisol levels were significantly regeneration. J Neuroimmunol 2007;184:100‑12. higher in TBM group as compared to aseptic meningitis 18. Elenkov IJ, Chrousos GP. Stress hormones, proinflammatory and and control group. CSF cortisol levels can be used as antiinflammatory cytokines, and autoimmunity. Ann N Y Acad Sci 2002;966:290‑303. a diagnostic marker in TBM pending its confirmation 19. Hellman L, Nakada F, Curti J, Weitzman ED, Kream J, Roffwarg H, et al. in larger cohort of TBM patients. This is the first study Cortisol is secreted episodically by normal man. J Clin Endocrinol Metab determining the level of cortisol in CSF in patients with 1970;30:411‑22. 20. Schwarz S, Pohl P. Steroid hormones and steroid hormone binding TBM. globulins in cerebrospinal fluid studied in individuals with intact and with disturbed blood‑cerebrospinal fluid barrier. Neuroendocrinology 1992;55:174‑82. Acknowledgments 21. Uhr M, Holsboer F, Müller MB. Penetration of endogenous steroid hormones corticosterone, cortisol, aldosterone and progesterone into the brain is enhanced in mice deficient for both mdr1a and mdr1b We thank the administration of M.S. Ramaiah medical college P‑glycoproteins. J Neuroendocrinol 2002;14:753‑9. and hospital, Bangalore, India for giving permission to conduct 22. Holub M, Beran O, Dzupová O, Hnyková J, Lacinová Z, Príhodová J, et al. the study. Cortisol levels in cerebrospinal fluid correlate with severity and bacterial origin of meningitis. Crit Care 2007;11:R41. 23. Holub M, Beran O, Lacinová Z, Cinek O, Chalupa P. Interferon‑gamma and cortisol levels in cerebrospinal fluid and its relationship to the etiology References of aseptic meningoencephalitis. Prague Med Rep 2006;107:343‑53.

1. Udani PM, Parekh UC, Dastur DK. Neurological and related syndromes in CNS tuberculosis. Clinical features and pathogenesis. J Neurol Sci How to cite this article: Mahale RR, Mehta A, Uchil S. Estimation of 1971;14:341‑57. cerebrospinal fluid cortisol level in tuberculous meningitis. J Neurosci Rural Pract 2015;6:541-4. 2. Murray CJ, Feechem RG. Adult mortality in the developing world. Trans R Soc Trop Med 1990;84:21‑2. Source of Support: Nil. Conflict of Interest: None declared.

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